<div class="pageContent">
	<form action="<?php echo url('card/timeagentpay');?>" method="post" onsubmit="return validateCallback(this,navTabAjaxDone)">
		<div class="pageFormContent" layoutH="60">
			
			
				<p><label>代理：</label>
				<select name="agent_id">
				<?php foreach ($agent as $k=>$v):?>
				<option value="<?php echo $k?>"><?php echo $v;?></option>
				<?php endforeach;?>
				</select>
				</p>
					<p>
				<label>储值卡卡号：</label>
				<input type="text" name="cardname" value="<?php echo $cardname;?>" />
				</p>
				<p>
				<label>储值卡密码：</label>
				<input type="text" name="password" value="<?php echo $password;?>"  />
				</p>
				
		</div>
		<div class="formBar">
			<ul>
				<li><div class="buttonActive">
						<div class="buttonContent">
							<button type="submit">充值</button>
						</div>
					</div></li>
				<li><div class="button">
						<div class="buttonContent">
							<button class="close" type="button">取消</button>
						</div>
					</div></li>
			</ul>
		</div>
	</form>
</div> 
